Extremities Feature

Adding Second Trauma Center: Good for Trauma Care?

Elizabeth Hofheinz, M.P.H., M.Ed. • Fri, October 28th, 2016

What happens when a new level II trauma center moves in near an academic level 1 trauma center…and then moves out? Researchers from University of Florida (UF) – Jacksonville and Baylor College of Medicine wanted to find out. Christopher H. Perkins, M.D. is an assistant professor of orthopedic surgery at Baylor College of Medicine. Dr. Perkins told OTW, “Cody Martin, M.D. and I chose to investigate this topic when I was an assistant professor at the University of Florida at Jacksonville. I was one of two orthopedic traumatologists and have since moved to Baylor College of Medicine. In 2012, the state of Florida opened four provisional level II trauma centers, all very close to current academic level I trauma centers. At that time, I was a trauma fellow at the University of Miami where the opening of Kendall Regional Medical Center as a trauma center significantly affected the volume of cases at Jackson Memorial Hospital.”

“UF Jacksonville experienced the same phenomenon with Orange Park Medical Center. We had a unique opportunity in Jacksonville to investigate this effect on a level I trauma center because Orange Park was open for one year and then its trauma status was suspended after verification. This allowed for a period of time before, during, and after closure to investigate the effect on the hospital and on the orthopedic trauma service. Other centers in Florida have remained open which does not allow for investigating the effect after closure.”

“For this work, we used census data including ICD-9 codes of patients seen in the Orange Park Medical Center emergency department (ED) and the related trauma center. We found that ED visits declined when the level 2 trauma centered opened and rebounded after its closure. However, the volume for the orthopedic trauma service did not statistically rebound after the closure of the level 2 trauma center. This suggests that patients with fractures were still being brought by ambulance or walking into the level 2 trauma center despite the change in status.”

“The opening of a non-academic level 2 trauma center close to an academic level I trauma center can have a significant impact on volume and potentially an impact on the quality of patient care. This also has implications on the quality of resident and medical student education and on the financial sustainability of academic level I trauma centers that are responsible for a large burden of indigent care.”

“The results of this study need to be considered when states are planning to designate new trauma centers. Trauma centers need to be strategically placed to maximize patient access to care in a timely fashion and patients who are more severely injured need to be appropriately triaged to a higher level of care to maximize outcomes. To our knowledge, this study is the first to highlight a problem that orthopedic traumatologists practicing at any academic level I trauma center know to be a reality.”

“Trauma surgeons need to be involved in the development of regional and state level trauma networks along with local and state officials to assure that improving patient outcomes remains the most important goal while protecting the viability of academic level I trauma centers to assure the training of future generations of residents and students.”

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Resiliency After Trauma Highlighted at This Year’s ATSPA Conference

Tracey Romero • Wed, March 7th, 2018

“Fostering Resiliency in the Trauma Community” is the theme of the American Trauma Society Pennsylvania Division’s annual conference at the Hershey Lodge and Convention Center on Wednesday, March 14 and Thursday, March 15, 2018. Topics will include elderly orthopedic trauma, sex trafficking, organ and tissue donation, and intimate partner violence.

J. Spence Reid, professor of orthopedic surgery and division chief of orthopedic trauma at the Penn State University College of Medicine and Milton S. Hershey Medical Center will be presenting “Orthopaedic Trauma in the Elderly: The Coming Epidemic” at the conference to put a spotlight on the increase in orthopedic trauma in the elderly. He will also outline the unique aspects of this patient population: bone fragility, increased activity levels, prevalence of joint replacements, and challenging post-injury care situations. Elderly trauma survivors will be there to share their experiences.

Another highlight of the American Trauma Society Pennsylvania Division (ATSPA) conference will be a talk by James W. Davis, M.D., FAC on “Intimate Partner Violence: The Rule of Thumb”. Davis, chief of trauma at Community Regional Medical Center and professor of clinical surgery and the program director of the Acute Care Surgery Fellowship Program at the University of California San Francisco Fresno Center for Medical Education and Research, will discuss how prevalent domestic violence is in the United States (it presents in at least one in five minutes seeking help in the emergency department) and how unfortunately physicians frequently fail to recognize the signs.

Some of the other presentations planned include:

“A Visual Potpourri of Pediatric Trauma”

“Unmasking Sex Trafficking: The Impacts on Healthcare”

“Saving Lives & Giving Hope Through Organ and Tissue Donation”

“Amish Trauma Care: Plain not Fancy”

“When A Hurricane Strikes – How Do We Evacuate Patients”

“Planning and Responding to an Active Shooter Event in The Workplace”

“State of the Art Resiliency: Humans are More than Hardware”

ATSPA is a non-profit trauma prevention education organization dedicated to reducing suffering, disability and death due to trauma. For more information on the conference and a full schedule visit https://www.atspa.org/schedule.

Duplicate Trauma Care in Houston Hospitals

Elizabeth Hofheinz, M.P.H., M.Ed. • Tue, August 23rd, 2016

Houston, we have a problem in the hospitals. A new study from Baylor College of Medicine has found that one out of five orthopedic trauma patients treated in a Houston public hospital emergency department (ED) are repeating the same care they had in another Houston ED.

“When an orthopedic trauma patient comes to an ED for care, ” says the August 15, 2016 news release, “there are three traditional channels of care following initial treatment: the patient is admitted for inpatient treatment, the patient is discharged with orthopedic follow up, or the patient is transferred to another medical center for orthopedic care. In the Houston area, a fourth channel has emerged: indirect referral.”

This work, led by Laura Medford-Davis, M.D., assistant professor in emergency medicine at Baylor College of Medicine, found that patients arrive at the next facility via independent transport and without medical records, meaning that have to have all the prior tests repeated.

“In the study, we examine 1, 162 ED patients who came to the ED with orthopedic injury over a six-month timeframe, said Dr. Medford-Davis. During this period, 20% of the patients had already been seen for their injury at another Houston-area ED, and almost 90% of those patients were uninsured, compared to those who came to the safety net hospital through more traditional referral methods.”

Dr. Medford-Davis told OTW, “We researched this topic because, while working at the public hospital emergency department, we noticed many patients presenting to follow-up fractures that were initially diagnosed and splinted at other emergency departments. This seemed like an inefficient way to care for these patients, and we wondered how frequently this was actually happening, and what the real impact was on the patients and hospitals involved.”

“Orthopedic surgeons themselves are not usually the ones referring these patients to the public emergency department for follow-up care. Most referrals come from staff at the initial emergency department, staff at the orthopedic surgeons' offices, or from the patients' friends and family. However, in order to protect the interests of patients with orthopedic injuries, orthopedic surgeons could take a proactive role by reaching out to develop processes with their on-call hospitals, their office staff, and the public hospital.”

“All hospitals and orthopedic surgeons in a community should decide how they want to care for their uninsured orthopedic population and then collaborate to develop a streamlined referral system.

Brain-Computer Interface Helps Paralyzed Man Feel

Elizabeth Hofheinz, M.P.H., M.Ed. • Sat, October 29th, 2016

Ten years ago Nathan Copeland was robbed of his ability to feel sensation in his arms and fingers when he was involved in a car accident. Copeland, a 30-year-old paralyzed man, has regained the sensation of touch. Thanks to technology developed by researchers at the University of Pittsburgh and the University of Pittsburgh Medical Center (UPMC), Copeland can now experience touch via a robotic arm that he controls with his brain. This project, a first-in-human milestone, was led by Robert Gaunt, Ph.D., assistant professor of physical medicine and rehabilitation at “Pitt.”

"The most important result in this study is that microstimulation of sensory cortex can elicit natural sensation instead of tingling, " said study co-author Andrew B. Schwartz, Ph.D., distinguished professor of neurobiology and chair in systems neuroscience, Pitt School of Medicine, and a member of the University of Pittsburgh Brain Institute, in the October 13, 2016 news release. "This stimulation is safe, and the evoked sensations are stable over months. There is still a lot of research that needs to be carried out to better understand the stimulation patterns needed to help patients make better movements."

Michael Boninger, M.D., professor of physical medicine and rehabilitation at Pitt, and senior medical director of post-acute care for the Health Services Division of UPMC, told OTW, “I saw during medical school how much technology could help people, and truly help them get better—be more independent. It worked well with my engineering degree and I found it rewarding. The move to brain computer interface (BCI) work was based on having great collaborators needed to build a team. Early on this was specifically Andy Schwartz and Doug Webber. Working in the BCI area offers a chance to transform a field.”

“Many orthopedic surgeons treat the spine or limb trauma that results in amputation and spinal paralysis. I think they can point to this work as something their patients can look towards as providing better function in the future. It might be a good way to introduce rehabilitation and the rehabilitation team that care for patients with amputation and spinal cord injury long term.”

“I have seen patients who see this ground breaking work and decide that they don’t need to do the hard work of rehabilitation.

New Trauma Study: the ‘Defined Approach’ Rules

Elizabeth Hofheinz, M.P.H., M.Ed. • Tue, January 30th, 2018

Researchers from the University of California Keck School of Medicine in Los Angeles and the University of Arizona College of Medicine in Phoenix have found that a “defined approach” to debriding open tibia fractures is safe and can reduce the need for flap coverage.

A co-author on the study, Geoffrey S. Marecek, M.D., assistant professor of Clinical Orthopaedic Surgery at Keck, told OTW, “Open tibia fractures are challenging injuries. So much thought needs to go into each step of treatment from the time the patient arrives in the emergency department.”

“Some of my fellowship mentors taught me to use a ‘defined approach’ when the traumatic wound was in a challenging location like the medial tibia, or when extending it might compromise the vascularity of the skin edges. It's a thoughtful approach, but medicine and orthopedics is filled with well-intentioned ideas that didn't work out well. We wanted to verify that it was a safe and effective approach to the debridement of open tibia fractures.”

“In order to try to get a fair comparison we excluded patients who had an OTA [Orthopaedic Trauma Association] Open Fracture Classification skin score of 3. That subset of patients typically goes on to flap coverage and a ‘defined surgical approach’ would not be useful for them.”

“Patients who had debridement through a ‘defined approach’ did not require flap coverage, compared to 19% of patients who had extension of the traumatic wound.”

“Undoubtedly this is partially due to surgeons selecting what they felt was the appropriate treatment. Perhaps as importantly, the rates of infection and unplanned reoperation were similar in both groups, suggesting that this approach is safe and effective.”

“Surgeons should ensure they do a thorough debridement, regardless of what technique they use. That being said, a thoughtful approach to making skin incisions may help some subset of patents avoid a flap.”

Depression, PTSD After Orthopedic Trauma Is Very Real

Elizabeth Hofheinz, M.P.H., M.Ed. • Fri, February 3rd, 2017

New work from the University of Maryland School of Medicine, Royal College of Surgeons in Ireland, and McMaster University, Ontario, Canada, has found that nearly one-third of patients suffer from depression and more than one-quarter of patients suffer from post-traumatic stress disorder (PTSD) after an acute orthopedic injury. The study, published in the January 2017 edition of the Journal of Orthopaedic Trauma, included 27 studies and 7,109 subjects.

Gerard P. Slobogean, M.D., M.P.H., is with the R. Adam Cowley Shock Trauma Center at the University of Maryland School of Medicine. Dr. Slobogean told OTW, “As an orthopaedic surgeon who practices at a busy trauma center, I have seen many patients struggle with the psychological impact of their injury and recovery. However, as a clinician-scientist, I discovered a paucity of research in this area to guide my clinical practice.”

“Support for the psychological distress of orthopaedic trauma patients is often overshadowed by a focus on the effective management of the patient’s fracture. I believe there is space in our field for a more holistic approach to identify and treat psychological distress in our patient population. This will not only have a positive effect on the mental health of our patients but will also likely have a positive impact on their fracture recovery. I believe our meta-analysis will help guide future research in this important domain.”